Section 1371 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1371
. A health care service plan, including a specialized health
care service plan, shall reimburse claims or any portion of any
claim, whether in state or out of state, as soon as practicable, but
no later than 30 working days after receipt of the claim by the
health care service plan, or if the health care service plan is a
health maintenance organization, 45 working days after receipt of the
claim by the health care service plan, unless the claim or portion
thereof is contested by the plan in which case the claimant shall be
notified, in writing, that the claim is contested or denied, within
30 working days after receipt of the claim by the health care service
plan, or if the health care service plan is a health maintenance
organization, 45 working days after receipt of the claim by the
health care service plan. The notice that a claim is being contested
shall identify the portion of the claim that is contested and the
specific reasons for contesting the claim.
If an uncontested claim is not reimbursed by delivery to the
claimants' address of record within the respective 30 or 45 working
days after receipt, interest shall accrue at the rate of 15 percent
per annum beginning with the first calendar day after the 30- or
45-working-day period. A health care service plan shall automatically
include in its payment of the claim all interest that has accrued
pursuant to this section without requiring the claimant to submit a
request for the interest amount. Any plan failing to comply with this
requirement shall pay the claimant a ten dollar ($10) fee.
For the purposes of this section, a claim, or portion thereof, is
reasonably contested if the plan has not received the completed claim
and all information necessary to determine payer liability for the
claim, or has not been granted reasonable access to information
concerning provider services. Information necessary to determine
payer liability for the claim includes, but is not limited to,
reports of investigations concerning fraud and misrepresentation, and
necessary consents, releases, and assignments, a claim on appeal, or
other information necessary for the plan to determine the medical
necessity for the health care services provided.
If a claim or portion thereof is contested on the basis that the
plan has not received all information necessary to determine payer
liability for the claim or portion thereof and notice has been
provided pursuant to this section, the plan shall have 30 working
days or, if the health care service plan is a health maintenance
organization, 45 working days after receipt of this additional
information to complete reconsideration of the claim. If a plan has
received all of the information necessary to determine payer
liability for a contested claim and has not reimbursed a claim it has
determined to be payable within 30 working days of the receipt of
that information, or if the plan is a health maintenance
organization, within 45 working days of receipt of that information,
interest shall accrue and be payable at a rate of 15 percent per
annum beginning with the first calendar day after the 30- or
45-working-day period.
The obligation of the plan to comply with this section shall not
be deemed to be waived when the plan requires its medical groups,
independent practice associations, or other contracting entities to
pay claims for covered services.